Sunday, 21 July 2013

Challenges in HIV Treatment

Although South Africa
reluctantly rolled out its government-funded ARV program in 2004, there are
still many challenges the government faces in regards to HIV treatment. Two of
the key challenges go hand in hand: ARV adherence and program retention.
Surprising to some is the fact that South Africa actually has an adherence rate
of 90%, one of the highest in the world (Achmat, 2007). This is primarily
thanks to the work of NGOs, who often place an emphasis on treatment literacy,
community awareness, and primary care clinics. However the same year that
Achmat’s paper was published, another study showed that South Africa was
suffering in terms of patient retention. The Cornell study found that after one
year in treatment there was only a 60-80% patient retention rate, which
steadily declined over time (Cornell, 2007). When looking at these papers side
by side, one is faced with a surprising juxtaposition: while in treatment
patients are very adherent to their medications, yet less patients are adherent
to the treatment itself. In the next few years South Africa will have to focus
on increasing patient retention rate by exploring the factors that may lead to
loss to follow up (LTFU).

Zackie Achmat, HIV activist, with Nelson Mandela

There are several factors that
can lead to increased numbers of LTFU patients. In my opinion the two most
important are computational errors and the over-burdening of primary care
clinics. Both the Cornell paper and the WHO Global Update on HIV Treatment
acknowledge that the estimates of LFTU patients are not completely accurate. It
is estimated that anywhere from 33-48% of LFTU patients are actually deceased,
and another 12-54% are “self-transfers” who access care at different places
(WHO, 2013). Yet this inconsistency is telling, as it reflects the current lack
of organization in the government ARV system. A successful program needs to be
able to keep track of its patients, whether or not they have died or they are
truly LFTU. However while the true number of LTFU patients may be lower than
estimated, there are still too many people not retained in the government
system. Much of this can be attributed to an over-burdened program that was
unprepared for the dramatic increase in patients in recent years. Many clinics
just do not have the staff or resources to continuously keep track of their
increasing number of patients, and with an estimated 6.3 million HIV-positive
South Africans it is not difficult to understand their plight (Class lecture,
6/25/13).

Thabo Mbeki...how many deaths is he responsible for?

Luckily there are ways to
improve retention rate and decrease the number of LTFU patients. According to
the WHO, “several studies…have shown that decentralizing ART services improves
retention in care” (WHO, 2013). The studies that they are referring to have
found that a district hospital’s retention rate is on average 80%, compared to
a regional hospital’s retention rate of 69%. We saw the benefits of
decentralized primary care first hand last week during our visit to Gugulethu.
At the ARV Club we visited there were less than 30 patients enrolled, which
means that it is easier for them to get their medications, and their absence is
noted if they do not show up. Another prospect for increasing retention rates
is the gradual introduction of FDCs in the public sector. While availability
may be currently limited to some prioritized group, taking one pill once a day
will certainly lead to more adherences, versus having to take three pills two
times a day (Class lecture, 6/25/13).

LTFU patients are a big
challenge facing the future of ART in South Africa. The main problem isn’t
getting people in treatment to adhere to their medications, but it’s getting
people to adhere to their treatment after testing HIV-positive. Many factors play
into retention rates: statistical errors, poor record keeping, burden of
resources on primary care, revival of traditional medicine, social stigma, and AIDS-related
deaths. However by focusing on record organization and continuing efforts to
decentralize ART care the picture of HIV retention may not look so bleak.